Gastrointestinal Bleeding During Hospitalization for Transcatheter Aortic Valve Replacement

Abstract

Introduction: Gastrointestinal bleeding (GIB) has been shown to be the most common bleeding complication post transcatheter aortic valve replacement (TAVR), likely due to multiple factors such as use of antiplatelets agents and anticoagulants, advanced age, chronic kidney disease, and prior history of GI disease. Yet there is a paucity of literature regarding the incidence and risk factors for GIB in this setting. The aim of this study was to determine the incidence and risk factors for GIB immediately following TAVR at UC Davis Medical Center (UCDMC). Methods: We retrospective reviewed medical records of 482 patients who were hospitalized for TAVR at UCDMC between January 1, 2012 to June 30, 2017. The incidence of both upper and lower GIB, and potential risk factors (age, antiplatelet use, chronic liver and kidney disease, Hb level, MCV, PPI use) during the same hospitalization were reviewed. The patterns of gastroenterology consultation, endoscopic findings and therapies were described. Multivariate regression analysis was done to identify independent risk factors for GIB. Results: Mean age was 81.5 years and 50% were males; 23% had CKD stage 3 or worse, 9.5% had history of prior GIB. Mean baseline Hb, MCV and platelet count were 11.9 g/dl, 91.6fl and 191000/ml, respectively. Dual antiplatelet therapy was used in 196 (40.6%) patients. Anticoagulation (mainly with warfarin) was used in 141 (29%) patients. PPIs and H2 receptor blockers were used in 167 (34.6%) and 20 (4%) patient, respectively. Incidence of GIB was 1.4% (7/482) with 5 cases of upper GIB, 1 small intestinal GIB and 1 lower GIB. Endoscopy (2 EGDs, 2 colonoscopies and one video capsule endoscopy) was performed in 5 patients, and showed esophagitis and angiodysplasia (1 in stomach, 1 in jejunum and 1 in cecum) in 2 and 3 patients respectively. Successful endoscopic intervention with argon plasma coagulation was performed in 3 patients with upper and lower angiodysplasia. 1 patient with a deep esophageal ulceration was not a candidate for endoscopic intervention. On multivariate regression, only a low hemoglobin level on admission was associated with increased likelihood of GIB (OR=1.53, CI 1.03-2.27). Conclusion: GIB is rare immediately post- TAVR. Angiodysplasia was the most common etiology in our series of 482 elderly patients, 23% of whom had advanced CKD. When indicated endoscopy is safe and successful in achieving hemostasis. Baseline anemia which is likely due to a preexisting GI lesion was a predictor of GIB in this setting.